Background
Minimum unit pricing (MUP) of £0.50 sterling per unit (10 ml or 8 g) was introduced in Scotland in 2018 in response to health harms from alcohol being disproportionately higher in Scotland compared with the rest of the United Kingdom, especially so in areas of deprivation. MUP is a measure recommended by the World Health Organization as a ‘best buy’ to reduce alcohol-related harms. As it targets those who buy the cheapest alcohol who are typically the heaviest drinkers, it has the potential to reduce inequalities of alcohol-related harms.1,2 Three years after implementation, MUP resulted in a 3% reduction in alcohol sales in Scotland, most evident in households that before MUP had purchased the most alcohol.1 A 2023 study to examine the impact of MUP on alcohol-related deaths and hospitalisations wholly attributable to alcohol use compared time periods before and after the introduction of MUP.3

Methods
The study involved a controlled interrupted time series design to estimate the impact of MUP in Scotland, while England (where MUP is not in place) was used as a control group. Routinely collected data on deaths and hospitalisations for causes wholly attributable to alcohol, along with the socioeconomic deprivation group, were examined.

Results
Alcohol-attributable deaths
Following the implementation of MUP in Scotland, there was a 13.4% decrease in the rate of alcohol-attributable deaths, equating to approximately 156 deaths wholly attributable to alcohol use prevented. Significant decreases in alcohol-attributable deaths were observed in chronic conditions (14.9% decrease), alcoholic liver disease (11.7% decrease), and alcohol dependence syndrome (23% decrease).

The study revealed that MUP resulted in significant reductions in wholly alcohol-attributable deaths among both males and females, those aged 35–64 years, those aged 65 years and older, and in the four most socioeconomically deprived decile groups.

Alcohol-attributable hospitalisations
As well as a reduction in alcohol-attributable deaths, a 4.1% decrease in wholly alcohol-attributable hospitalisations was also observed during the study period. Although chronic conditions decreased by 7.3%, acute conditions increased by 9.9%, offsetting the significant reduction observed. Hospitalisations for alcoholic liver disease decreased by 9.8%, alcohol psychoses decreased by 7.2%, although alcohol dependence syndrome hospitalisations increased by 7.2%.

MUP led to insignificant reductions in wholly alcohol-attributable hospitalisations among males, those aged 35–64 years, and as with wholly alcohol-attributable deaths, those in the four most socioeconomically deprived decile groups.

Discussion
This study adds to the evidence that MUP is effective in reducing alcohol-related harms, demonstrating a 13% reduction in wholly alcohol-attributable deaths in the study period. A 4% reduction in wholly alcohol-attributable hospitalisations was also estimated, the equivalent of 411 hospitalisations per year
on average.

The study confirmed that MUP had a positive impact in tackling deprivation-based health inequalities in alcohol-related harms, as declines in hospitalisations and deaths were more evident among those in the lower socioeconomic areas. Alcohol-attributable deaths were evident among males and females and those aged 35 years and over, but reductions were not observed among those aged 16–34 years.

The implementation of MUP resulted in a worsening of acute outcomes for deaths and hospitalisations wholly attributable to alcohol. The authors suggest a potential explanation is that certain subgroups may have reduced their expenditure on food or reduced their food intake to compensate for the price increase for alcohol products, resulting in faster intoxication or poisoning. It has been reported elsewhere that MUP may have resulted in switching to higher alcohol-by-volume products (e.g. cider to spirits) leading to quicker intoxication.4

Despite the increase in acute effects, overall this study supports the theory of change which was the basis for the policy being implemented. This is that an overall reduction in alcohol sales (3% in the 3 years following MUP being introduced) would result in a reduction in alcohol-related deaths and hospitalisations and, importantly, tackle alcohol-related health inequalities.

1    Giles L, Mackay D, Richardson E, et al. (2022) Evaluating the impact of minimum unit pricing (MUP) on sales-based alcohol consumption in Scotland at three years post-implementation. Edinburgh: Public Health Scotland. Available from: https://www.drugsandalcohol.ie/37516/

2    World Health Organization (2017) Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: World Health Organization. Available from: https://www.drugsandalcohol.ie/37100/

3    Wyper GMA, Mackay D, Fraser C, et al. (2023) Evaluating the impact of alcohol minimum unit pricing (MUP) on alcohol-attributable deaths and hospital admissions in Scotland. Edinburgh: Public Health Scotland. Available from: https://www.drugsandalcohol.ie/38412/

4    Holmes J, Angus C, Boyd J, et al. (2022) Evaluating the impact of minimum unit pricing in Scotland on people who are drinking at harmful levels. Edinburgh: Public Health Scotland. Available from: https://www.drugsandalcohol.ie/36398/